IBD: When to operate and when to punt

LAS VEGAS (FRONTLINE MEDICAL NEWS) – Patients with inflammatory bowel disease who are in need of a surgical intervention can pose a special challenge to surgeons who encounter these patients only occasionally.

The question of whether to perform surgery or refer a patient to a higher-volume specialty center can depend on proximity. In some cases, a specialty center isn’t close, or the patient can’t tolerate the required travel. In fact, a recent study showed that 85.8% of IBD patients are treated surgically in hospitals that treat fewer than 50 patients per year (Am J Gastroenterol. 2008;103:2789-98).

In a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education, Larry Whelan, MD, discussed some of the challenges these patients pose and offered guidance on which cases are best referred to high-volume centers, and the best way to proceed in emergencies.

IBD patients at high-volume centers have lower mortality than do those in low-volume centers, but patients treated at lower-volume centers tend to be sicker, and studies have shown no significant difference in complication rate. This suggests that surgeons shouldn’t be afraid to tackle these cases, according to Dr. Whelan, chief of colorectal surgery at Mount Sinai West, New York.

If you get an IBD case and you don’t see a lot of those, how do you decide what to do about it, and should you just refer it to a high-volume center?” said Dr. Whelan.

These patients are often under complex medical management, frequently spanning years, and this is an important factor in surgical decisions. They are often on multiple medications, including steroids, and most patients these days are taking monoclonal antibodies, said Dr. Whelan. The latter in particular can lead patients to be susceptible to infections. “These things can all affect decision making,” said Dr. Whelan.

Sometimes the nutritional status of IBD patients is poor, and most of the time, surgery is elective in these patients. So surgery can often be delayed for a month or more to allow time for nutritional status to improve, and this gives time for a patient to go off monoclonal antibodies, and for the physician to arrange for a referral to a high-volume center, if that seems the wisest course.

Surgery should not be considered without a gastrointestinal specialist who is comfortable in managing these patients. “Having someone who knows when to operate and not to operate, and how to handle medication, is really important,” said Dr. Whelan.

Certain cases should definitely be referred out. Ileal pouches are one. Another is a Crohn’s disease patient with multiple points of obstruction. “That may be one that you’re better off to punt,” said Dr. Whelan. Other cases include patients under complex medical management, when there is no experienced GI specialist available to help.

Emergencies require quicker decisions. In ulcerative colitis, emergency cases may include toxic megacolon, perforated colon, or obstruction from either a stricture or cancer, as well as bleeding in rare cases. Scenarios in Crohn’s disease include perforation with sepsis, inaccessible abscess, and, most commonly, obstruction resulting from fibrous stricture or acute inflammation.

When surgery is required, what’s the best choice? Dr. Whelan emphasized keeping it simple. Redo ileal pouches and ileal pouch excisions should generally be avoided. “Even if you do [pouches] often. It’s not the smartest way to go. These patients are almost all on immunosuppressive medications … to make an operation that’s already big even bigger often doesn’t work out well,” he said.

In emergency chronic ulcerative colitis cases, the safest choice is total abdominal colectomy plus end ileostomy. Dr. Whelan discourages surgeons from considering proctectomy and ileal pouch in emergency cases. A number of studies have shown that delaying pouch surgery is associated with fewer minor and major adverse events, and lower reoperation rates, he said. “If you do these operations on an immunosuppressed population, they don’t do as well,” said Dr. Whelan.

Crohn’s disease emergencies can often be managed nonsurgically. Most patients have phlegmon, fistulae, or a partial obstruction. Intravenous antibiotics, percutaneous drainage, hydration, and boosting nutritional status are good options. In cases where an obstruction requires surgery, and the surgeon isn’t comfortable performing stricturoplasty, “you want to limit the resection as best you can,” he said.

Dr. Whelan disclosed financial relationships with Ethicon Endosurgery and Olympus Corporation. Global Academy for Medical Education and this news organization are owned by the same parent company.”

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